HospitalInspections.org

Based on record review, interview, policy review, and personnel record review the facility failed to determine if all patients admitted to the facility had an advanced directive, provide information regarding advance directives, and provide written notice of its advance directive policies. This failure affected 19 of 20 patients reviewed in the sample. Additionally, the facility failed to ensure that its staff were provided education regarding its policies and procedures on advance directives and failed to provide documented evidence that community education was provided regarding advance directives.

Findings Include:

1. Review of medical records determined that Patient 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19 and 20 had no documented evidence hospital staff: asked if they had an advanced directive; offered information about advance directives; and provided written notice of the facility's advance directive policies.

In a staff interview on 02/07/19 at 1:35 PM, Staff B, Acute Registered Nurse (RN), explained that the admitting nurse or business office staff should be addressing, advance directives with the patients on admission, and completing the facility's "Treatment Authorization and Privacy Acknowledgement" form including statement 17 related to Advance Directives.

The surveyor requested to speak to a staff member that currently admitted patients in an attempt to resolve the advance directive issue. The request for this interview went unanswered. When the surveyor inquired if patients are provided a hand out or information packet regarding Advance Directives upon admission, the response was "no." During continued interview with Staff B, a blue folder titled "Patient Information Booklet," located on a shelf in a breakroom behind the nurses' station, contained written information regarding advance directives. Staff B confirmed that if and/or when patients were provided the admission booklet, it had not been documented in the sampled patients' medical records as stated in the CAH policy.

A review of the facility's policy titled, "Advanced Directives" last reviewed on 06/03/17, showed, at the time of admission as a hospital patient, the individual will be provided with written information concerning the individual's rights under state law, to make decisions concerning such medical or surgical treatment, and the right to formulate advance directives. This information shall be provided by the admissions clerk or admitting nurse, as evidenced by documentation on the hospital admission sheet. There shall be documentation in the individuals medical record whether the individual has executed any advance directives. The following employees shall be required to attend an inservice regarding these policies and procedures: all nurses responsible for patient admissions. Community education programs and information shall be provided by Medical Records and the Nursing Department.

A review of the facility's policy titled, "Hospital Staff Orientation," last reviewed on 06/03/17, showed, personnel employed will undergo a general orientation consisting of the following subjects: Patient Care and Advance Directives. Records of attendance will be kept in the employee files.

Document review of the facility's form, "Treatment Authorization and Privacy Acknowledgement," revised 09/24/13, included statement 17 with the following questions: "Do you have a living will? Do you have a Medical Durable Power of Attorney (DPOA)? If yes, is the living will or DPOA on file? If no, were you given Advanced Directive Education Material?" The answers for the questions were in a yes/no format but were left blank on the form in the sampled patient's medical records.

A review of the admission packet for the facility's patients showed that there was no additional information regarding advance directives except statement 17 on the Treatment Authorization form.

A review of personnel files showed no documented evidence that the staff received education relating to the facility's policies and procedures regarding advance directives.

There was no documented evidence provided by the facility regarding provision of advance directive education to the community.

Based on observation, interview, and medical equipment inspection records, the facility failed to ensure that all essential medical equipment was identified as currently inspected and tested for performance. Specifically, an electrical machine located in the surgery/central supply room used to indicate a surgical instrument sterilization failure, (Attest) was found to be in use and had not been inspected by a biomedical technician. This deficient practice had the potential to cause serious wound infections for all surgical care patients.

Findings Include:

An observation on 02/05/19 at 10:30 AM of the central sterilization/supply room: Staff E, Central Supply/Surgery Technician examined the "Attest Rapid Readout Biological Indicator" (Attest-an electrical machine test system that provides a direct measurement of surgical instruments decontamination by process incubation). The machine had no inspection sticker. Staff E stated "I was here during the equipment inspection and I know it (Attest) was not inspected. I didn't know it had to be. I always keep it in this closet and he may not have seen it.

Review of the hospital's equipment list undated, showed the Attest machine was not found on the list as part of the hospital equipment.

In an interview on 02/06/19 at 2:20 PM, Staff D Biomed technician stated, "We have been inspecting the equipment at the hospital since 2012. We did a sweep in 2015 when we renewed the contract and the Attest incubator was not on the list. I checked the equipment list based on the serial number of the machine and the Attest was not on it. We have never inspected that machine, but I can inspect it tomorrow."

In an interview on 02/07/19 at 12:45 PM, Staff A Chief Executive Officer stated, "We don't have any surgeries scheduled until 02/13/19. We will not touch another surgical patient until the equipment has been inspected and all surgical instruments have been re-sterilized with each load tested. The technician is here now to inspect the Attest."

Based on interview and facility policy review, the facility failed to ensure the governing body/responsible party developed, implemented, and monitored patient care policies related to advance directives, surgical services, quality assurance activities, patient's rights and emergency preparedness. This deficient practice had the potential to impact the quality of health care, safety of patients and the environment of health care.

Findings Include:

1. The facility failed to determine if all patients admitted to the facility had an advanced directive, provide information regarding advance directives, and provide written notice of its advance directive policies. This failure affected 19 of 20 patients reviewed in the sample. Additionally, the facility failed to ensure that its staff were provided education regarding its policies and procedures on advance directives and failed to provide documented evidence that community education was provided regarding advance directives. Refer to C-0151.

2. The facility failed to ensure that essential medical equipment used in surgical services was identified and currently inspected and tested for performance. Specifically, an electrical machine located in the surgery/central supply room used to indicate a surgical instrument sterilization failure, (Attest) was found to be in use and had never been inspected or added to the equipment inspection list. This deficient practice had the potential to cause serious wound infections for all surgical patients in the facility. Refer to C-0222.

3. The facility failed to develop a Quality Assurance program to evaluate patient care services effecting patient health and safety. Specifically, the facility to develop a Quality Assurance/Improvement Plan, failed to conduct Quality Assurance committee meetings, failed to review and monitor facility patient care policies, failed to examine important aspects of patient care, communicate relevant findings with hospital staff, and failed to provide data, for problem identification, resolution, and improvement. Refer to C-0330.

4. The facility failed to inform its swing bed patients of their rights and responsibilities both orally and in writing, in a language the patient understands prior to or upon admission to the facility. Receipt of any such information must be acknowledged in writing. This failure affected three of three swing bed patients (Patients 3, 4, and 7) reviewed in the sample. Refer to C-0360.

5. The facility failed to ensure compliance for the Condition of Participation requirements for the Emergency Preparedness Plan (EPP). These failures had the potential to affect patients receiving services in the facility. Additionally, these failures had the potential to hinder the facility's ability to prepare for emergency situations and keep patients and staff/visitors safe during an emergency event. Refer to the Emergency Preparedness 2567.


Review of the undated job description for Staff A, showed, Chief Executive Officer...department Administration. Supervision of department heads...all hospital staff. Administers and directs all functions of the facility. Assigns department heads and delegates appropriate work throughout the facility to such individuals. Informs the Board of Trustees appropriately of functions within the facility...reports and oversees all functions throughout the facility and is responsible for the proper day-to-day management...analyzes operations to evaluate performance...and to determine areas of potential program improvement, or policy change...appoints department heads or managers, and assigns or delegates responsibilities to them.

Based on observation, staff interviews and manufacturer's manual review, the facility failed to ensure that essential medical equipment used in surgical services was identified and currently inspected and tested for performance. Specifically, an electrical machine located in the surgery/central supply room used to indicate a surgical instrument sterilization failure (Attest), was found to be in use and had never been inspected or added to the equipment inspection list. In addition, the facility failed to utilize the Attest biological indicator machine as recommended by the manufacturer and per hospital policy as evidenced by failing to use a biological indicator in every load and failing to document the items loaded, date of the loads, load number and cycle number. This deficient practice had the potential to cause serious wound infections for all surgical patients in the facility.

Findings Include:

An observation on 02/05/19 at 10:30 AM of the central sterilization/supply room: Staff E, Central Supply/Surgery Technician examined the "Attest Rapid Readout Biological Indicator". The Attest machine had no inspection sticker. Staff E stated "I was here during the equipment inspection and I know it (Attest) was not inspected. I didn't know it had to be. I always keep it in this closet and he may not have seen it. I only use it in the flash sterilizer with a load (surgical instruments) every other week. I don't check every load."

Review of the manufacturer's instructions manual, undated, for the Attest biological indicator for steam sterilization, showed, For optimal quality assurance of hospital-sterilized goods, we recommend that the Attest biological indicator be used to monitor every load of steam sterilized supplies...identify the Attest indicator by noting the sterilizer and load numbers, and the processing date on the label...place the test pack in the most challenging area of the sterilizer; generally, the bottom shelf near the door and over the drain...the Attest indicator label changes from rose to brown when processed...incubate the indicator...a final determination of sterility can be made at 24 hours of incubation...record results. Examine the processed indicator for a color change toward yellow (evidence of bacterial growth). Record results...a yellow color in the control vial demonstrates incubation of viable spores, and medium to promote rapid growth.

Review of the hospital policy for biological monitoring dated 06/21/2011, showed, Biological monitors will be included in sterilization for every load processed...biological monitor will not run on diagnostic cycle, but on the sterilization cycle.

Review of the Attest log book dated 01/09/18 through 01/30/19 used by Staff E, showed the surgical instrument sterilization to verify a final determination of sterility, was not performed on every instrument load. The log book showed the Attest was used every other week.

The facility's staff was not following the manufacturer's instructions by having evidence the sterilizer was being tested with the Attest indicator with every load.


Review of the hospital policy for sterilizer loading dated 05/21/2011, showed, Proper sterilizing between patient use to avoid cross contamination and ensure sterilization. Be sure to document each item loaded into the sterilizer into the log book with date of load, load number, and cycle number.

Review of the documentation of steam sterilization (A small steno pad) used by Staff E dated 12/11/17 through 11/12/18, showed the entries were without items loaded, date of the loads, load number and cycle number.

The facility's staff failed to follow the facility policy by not documenting items loaded, date of load and cycle number.


Review of the central supply/surgical tech job description dated July 2009, showed, Ensures proper cleaning and sterilization of all instruments for facility...maintains proper logs on all sterile loads...ensures sterilizer is properly cleaned and functional while performing biological testing...ensures proper cleaning, disinfecting and organization of all instruments for sterilization after surgery.

In an interview on 02/05/19 at 11:30 AM, Staff E stated, "I haven't used the Attest with every load and I have been the tech for 3 years. They told me to test it every other week. We have been using this steno pad since 2012. I know I should have been dating the load information."

The facility's staff failed to follow the job description by not performing biological testing of all surgical instruments.


Review of the hospital's equipment list undated, showed the Attest machine was not found on the list as part of the hospital equipment.

In an interview on 02/06/19 at 2:20 PM, Staff D Biomed technician stated, "We have been inspecting the equipment at the hospital since 2012. We did a sweep in 2015 when we renewed the contract and the Attest incubator was not on the list. I checked the equipment list based on the serial number of the machine and the Attest was not on it. We have never inspected that machine, but I can inspect it tomorrow."

Review of a facility service contract dated 01/01/15, showed, Crawford Diversified Services agrees to provide preventive maintenance inspections for equipment listed...hospital will provide appropriate history for each piece of equipment...contract provides for inspection and repair of listed equipment...preventive maintenance refers to a procedure ensuring proper equipment operation and calibration. The procedure includes: inspection for mechanical defects, cleaning of interior and exterior...calibration verification per manufacturer's specification.


In an interview on 02/07/19 at 12:45 PM, Staff A Chief Executive Officer stated, "We don't have any surgeries scheduled until 02/13/19. We will not touch another surgical patient until the equipment has been inspected and all surgical instruments have been re-sterilized with each load tested. The technician is here now to inspect the Attest."

Based on policy review and interview the facility failed to develop a Quality Assurance program to evaluate patient care services affecting patient health and safety. Specifically, the facility failed to develop a Quality Assurance/Improvement Plan, failed to conduct Quality Assurance committee meetings, failed to review and monitor facility patient care policies, failed to examine important aspects of patient care, communicate relevant findings with hospital staff, and failed to provide data, for problem identification, resolution, and improvement.

Findings include:

In an interview on 02/07/19 at 11:30 AM, Staff G Quality Assurance/Risk Management stated, "I have been responsible for the QA program since August of last year. We don't have a plan based on all services provided by the hospital. The plan is what we used last year. I asked the department heads to provide a quality improvement plan for their department but none of them have done so. They said they were too busy getting their own work done. I don't have documentation of meetings, audits or reports. I haven't had education on how to do this and no one has helped me. There are no quality improvement projects and we have no audits or reports related to patient care. We have never met to review policies. Refer to C-0336.

Review of the facility policy for Quality Assurance/Improvement dated 03/14/18, showed, The purpose of the Quality Assurance/Improvement activities in the departments is to monitor and evaluate the quality and appropriateness of care provided on an ongoing basis, correct any known, suspected or potential problems, and to provide documentation to support the quality improvement activities. The QI activities of the department are to be consistent with the plan of the hospital. Departments having direct patient care functions will have ongoing monitoring of designated occurrences.

Based on interview and hospital policy review, the facility failed to develop a Quality Assurance program to evaluate patient care services affecting patient health and safety. Specifically, the facility to develop a Quality Assurance/Improvement Plan, failed to conduct Quality Assurance committee meetings, failed to review and monitor facility patient care policies, failed to examine important aspects of patient care, communicate relevant findings with hospital staff, and failed to provide data, for problem identification, resolution, and improvement.

Findings Include:

In an interview on 02/07/19 at 11:30 AM, Staff G Quality Assurance/Risk Management stated, "I have been responsible for the QA program since August of last year. We don't have a plan based on all services provided by the hospital. The plan is what we used last year. I asked the department heads to provide a quality improvement plan for their department but none of them have done so. They said they were too busy getting their own work done. I don't have documentation of meetings, audits or reports. I haven't had education on how to do this and no one has helped me. There are no quality improvement projects and we have no audits or reports related to patient care. We have never met to review policies."

In an interview on 02/07/19 at 12:45 PM, Staff A Chief Executive Officer, stated, "I've been here 9 months. There was no QA when I got here. I was told there was a QA meeting in October, but I was not able to attend. I believe there was a meeting in January, but I was out of the facility. I didn't ask to see the agenda or minutes and I haven't seen any audits or reports from any of the department heads. I don't have a reason and I don't have any excuse. When I got here the building had to have a new roof, the surgical table was leaking hydraulic fluid. The surgical program wasn't on my radar. I agree there is no QA plan. All 14 components of QA are missing, and I have not directed the QA nurse to have the meetings, start audits or reports. I have not seen any documentation. I will begin as soon as the survey is over."

In an interview on 02/07/19 at 4:00 PM, Staff I, Chief of Staff stated "I was hired by the hospital on 01/17/19 as chief of staff. I've provided physician services here for the past 22 years and I can tell you the last three years there have been many changes in leadership, especially in the past year. I believe QA is important and we need to make some improvements. Quality reports should have been provided to the medical staff. I haven't attended a QA meeting and haven't been invited to one. I believe QA was overlooked because of all the problems with the building."

Review of the facility policy for Quality Assurance/Improvement dated 03/14/18, showed, The purpose of the Quality Assurance/Improvement activities in the departments is to monitor and evaluate the quality and appropriateness of care provided on an ongoing basis, correct any known, suspected or potential problems, and to provide documentation to support the quality improvement activities. The QI activities of the department are to be consistent with the plan of the hospital. Departments having direct patient care functions will have ongoing monitoring of designated occurrences...the ongoing monitors used by the departments will be objective and measurable and will reflect all the services of the department. These ongoing monitors will serve as a guide to the appropriate management of the activities within the department...provide data for the purpose of problem identification, resolution, and evaluation of effectiveness.

Review of the Quality Manager job description signed 08/29/18, showed, Coordinates the hospital-wide Quality Improvement program to ensure consistency with hospital policies, procedures and philosophy and to maintain and improve the quality of care given to the patient. Maintains communications with administration, medical staff and department heads regarding Quality Improvement activities...recommends tracking and monitoring systems that are identified as problematic areas, management problems, policy and procedure, legality issues, personnel issues in relation to patient care...assists departmental managers in identifying and developing plans for quality improvement within their areas...generates reports for staff as necessary. Prepares quality improvement study design including monitoring and evaluation activities and medical record reviews...provides data collection and report development support for quality improvement studies and performance improvement projects.

Based on record reviews and interviews the facility failed to inform its swing bed patients of their rights and responsibilities both orally and in writing, in a language the patient understands prior to or upon admission to the facility. Receipt of any such information must be acknowledged in writing. This failure affected three of three swing bed patients (Patients 3, 4, and 7) reviewed in the sample.

Findings Include:

1. A review of medical records for swing bed Patients 3, 4 and 7 showed no evidence that the facility's staff provided oral and written notices of patient's rights to the patients at the beginning of their stay.

During an interview on 02/07/19 at 2:03 PM, with Staff B, Registered Nurse (RN), it was confirmed there was no written documentation of the patient rights that would be reviewed with and provided to the facility's swing bed patients. Staff B provided two of the facility's forms titled "Treatment Authorization and Privacy Acknowledgement" and "Notice of Privacy Practices" as the patient rights information that should be provided to patients on admission.

Staff B later provided a form titled "Patient Rights" which was a copy of the Federal Register, update 06/12/17, Section 482.13 Condition of Participation: Patients' Rights. The majority of the "Patient Rights" form addressed the use of restraints for acute medical and surgical care.

During an interview on 02/07/19 at 2:45 PM, Staff A, Chief Executive Officer (CEO), confirmed that the "Patient Rights" information form that was provided by Staff B was a copy of the Federal Regulations and was not written in a patient friendly manner.

Document review of the facility's policies failed to include a policy that addressed patient rights or the administration of those rights to patients.

Document review of the facility's admission packet did not include written patient rights information..

Based on interview and review of facility documentation, the facility failed to ensure compliance for the Emergency Preparedness Plan (EPP) as evidenced by the failure to: 1) develop an EPP; 2) document a review and update the EPP annually; 3) provide and all-hazards risk assessment; 4) ensure the EPP addressed their patient population, the type of services that could be provided and delegation of authority; 5) provide a process for collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts. establish policies and procedures to address subsistence needs for staff and patients during an emergency or disaster; 6) ensure the development of a Communication's Plan; 7) establish policies and procedures to address subsistence needs for staff and patients during an emergency or disaster situation; 8) establish policies and procedures to address a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency, a method to document the specific name and location of the receiving facility or other location; 9) to establish policies and procedures to address evacuation procedures in the event of an emergency; 10) establish policies and procedures to address a means to shelter in place in the event of an emergency; 11) establish policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency; 12) establish policies and procedures to address the use of volunteers in an emergency; 13) address arrangements with alternative facilities to receive patients; 14) address the role of the facility under waiver in the provision of care and treatment at an alternate care site; 15) develop a written emergency communications plan; 16) ensure the contact information had a documented annual review and update; 10) to develop a written training and testing program based on the emergency plan and ensure that the training and testing program was reviewed and updated at least annually; 17) develop an emergency communications plan that complies with Federal, State and local laws; 18) develop and maintain an emergency communication plan that included a primary and alternate means for communication with staff and emergency management agencies; 19) develop an emergency communications plan that complies with Federal, State and local laws; 20) develop an emergency communications plan that reviewed the means of providing information about the facility's occupancy, needs and its ability to provide assistance to the Incident Command Center; 21) develop a written training and testing program based on the emergency plan and ensure that the training and testing program was reviewed and updated at least annually; 22) develop initial training for new and existing staff, individuals providing services under arrangement, and volunteers. Provide training annually and maintain documentation of training; 23) conduct exercises to test the emergency plan at least annually. These failures had the potential to affect all patients receiving care in the facility. Additionally, these failures potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

1. The facility's staff failed to ensure the development of an Emergency Program (EPP). Refer to tag E0001.
2. The facility's staff failed to ensure the Emergency Preparedness Plan (EPP) was developed, evaluated and updated on an annual basis. Refer to tag E0004.
3. The facility's staff failed to provide an all-hazards risk assessment that was reviewed and updated annually. Refer to tag E0006.
4. The facility's staff failed to ensure the EPP addressed their patient population, the type of services that could be provided and delegation of authority. Refer to tag E0007.
5. The facility's staff failed to provide a process for collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts. Refer to tag E0009.
6. The facility's staff failed to ensure that the development of a Communication's Plan. Refer to tag E0013.
7. The facility's staff failed to establish policies and procedures to address subsistence needs for staff and patients during an emergency or disaster situation. Refer to tag E0015.
8. The facility's staff failed to establish policies and procedures to address a system to track the location of on-duty staff and sheltered patients in the Facility's care during an emergency, a method to document the specific name and location of the receiving facility or other location. Refer to tag E0018.
9. The facility's staff failed to establish policies and procedures to address evacuation procedures in the event of an emergency. Refer to tag E0020.
10. The facility's staff failed to establish policies and procedures to address a means to shelter in place in the event of an emergency. Refer to tag E0022.
11. The facility's staff failed to establish policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency. Refer to tag E0023.
12. The facility's staff failed to establish policies and procedures to address the use of volunteers in an emergency. Refer to tag E0024.
13. The facility's staff failed to ensure address arrangements with alternative facilities to receive patients. Refer to tag E0025.
14. The facility's staff failed to address the role of the facility under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site. Refer to tag E0026.
15. The facility's staff failed to develop a written emergency communications plan. Refer to tag E0029.
16. The facility's staff failed to ensure that all contact information had been reviewed and updated at least annually. Refer to tag E0030.
17. The facility's staff failed to develop an emergency communication plan that complies with Federal, State and local laws. Refer to tag E0031.
18. The facility's staff failed to develop and maintain an emergency communication plan that included a primary and alternate means for communication with staff and emergency management agencies. Refer to tag E0032.
19. The facility's staff failed to develop an emergency communication plan that complies with Federal, State and local laws. Refer to tag E0033.
20. The facilities staff failed to develop an emergency communications plan that reviewed the means of providing information about the facility's occupancy, needs and its ability to provide assistance to the Incident Command Center. Refer to tag E0034.
21. The facility's staff failed to develop a written training and testing program based on the emergency plan and ensure that the training and testing program was reviewed and updated at least annually. Refer to tag E0036.
22. The facility's staff failed to develop initial training for new and existing staff, individuals providing services under arrangement, and volunteers. Provide training annually and maintain documentation of training. Refer to tag E0037.
23. The facility's staff failed to conduct exercises to test the emergency plan at least annually. Refer to tag E0039.

In an interview with the CEO on 02/27/19, the CEO stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM), stated, "There is not a plan."

Based on document review and interview, the facility's staff failed to ensure their Emergency Preparedness Plan was reviewed and updated annually. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the CAH's binder titled, "Emergency Preparedness" showed no evidence of a written Emergency Preparedness Plan.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM), stated, "There is not a plan." Staff G explained that there was a tornado plan, but Staff G was unable to locate that plan. Staff G explained that he/she assumed the responsibility for the CAH's Emergency Preparedness in August 2018. Staff G explained that the facility's staff had worked on updating and rewriting the facility's Emergency Preparedness Plan, but the plan was not complete and had not been approved by the facility's governing body. Staff G was not aware that a facility's Emergency Preparedness Plan needed to be reviewed and updated on a yearly basis.

In an interview on 02/07/19 at 12:55 PM, the Chief Executive Officer (CEO), Staff A, confirmed that there was not a written Emergency Preparedness Plan. Staff A explained that a facility plan was being developed but had not been completed at the time of the survey.

Based on document review and interview, the facility's staff failed to provide an all-hazards risk assessment for their Emergency Preparedness Plan that was to be reviewed and updated annually. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence of a risk-assessment based on an all-hazards approach specific to the geographic location of the facility that encompasses all potential hazards.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that she was not aware of a risk assessment being completed for the facility. Staff G explained that the possibility of tornadoes and farming incidents (chemical) would be risks for the local geographic area, and there was no emergency plan.

Based on document review and interview, the facility's staff failed to provide an Emergency Preparedness Plan that addressed their patient population, the type of services that could be provided, delegation of authority and succession plans. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence of an Emergency Preparedness Plan (EPP).

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that the facility did not have an Emergency Preparedness Plan.

Based on document review and interview, the facility's staff failed to provide a process for collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response to an emergency situation. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence of an Emergency Preparedness Plan (EPP) and no process for collaboration with emergency preparedness officials during an emergency or disaster situation.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that there was not a written process for collaboration with officials or documentation of the facility's staff's efforts to contact such officials.

Based on document review and interview, the facility's staff failed to ensure the development of policies and procedures based on the emergency plan, a community and facility risk assessment and communication plan. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence of a communication plan or policies and procedures based on their risk assessment.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM), was not aware of any development and/or implementation of emergency preparedness policies and procedures, a written communication plan or a risk assessment for the facility.

Based on document review and interview, the facility's policies and procedures failed to address subsistence needs (such as adequate energy sources, emergency lighting, fire detection, extinguishing, alarm systems, sewage and waste disposal) for staff and patients during an emergency or disaster situation. This failure had the potential to affect all patients receiving care in the facility and all staff working in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients and staff safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence that the facility's policies and procedures addressed subsistence needs for staff and patients during an emergency or disaster. Such needs would include adequate alternate energy sources necessary to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions; emergency lighting, fire detection, extinguishing, and alarm systems. It was determined that the facility did have an emergency generator but there was no written policy and procedure that addressed the operation or maintenance of the generator during a disaster. Additionally, there were no policies to address the provision for sewage and waste disposal in an emergency.

A review on 02/07/19 of the facility's Policy and Procedure Manuals showed no documented evidence that the facility's policies and procedures addressed subsistence needs for staff and patients during an emergency or disaster. Further, there were no policies to address the provision for sewage and waste disposal.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM), was not aware of any policies and procedures that address subsistence needs for staff and patients during an emergency or disaster. .

Based on document review and interview, the facility's Emergency Preparedness Plan failed to address a system to track the location of on-duty staff and sheltered patients in the facility's care, during an emergency, or a method to document the specific name and location of the receiving facility or other location for evacuations in an emergency. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder and Policy and Procedure Manuals showed no documented evidence that the facility's staff had policies and procedures to address a system to track the location of on-duty staff and sheltered patients in the facility's care, during an emergency, or a method to document the specific name and location of the receiving facility or other location for evacuations in an emergency.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that there was a call list for staff that was managed by the Human Resources Department. Staff G explained that if telephone or cell service was not working they would have to drive and locate staff at their residences. Staff G explained that the facility did not have a policy or procedure in place to track the location of off/on-duty staff and sheltered patients in the facility's care during an emergency.

Based on document reviews and interview, the facility's Emergency Preparedness Plan failed to address evacuation procedures in the event of an emergency. This failure had the potential to affect all patients receiving care in the facility and staff/visitors in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder and Policies and Procedures showed no documented evidence that the facility's staff had developed policies and procedures that addressed evacuation procedures in the event of an emergency. Specifically, at a minimum, the safe evacuation from the facility, including care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) was unable to locate policies and procedures that addressed evacuation procedures. Staff G explained that they would utilize Dickinson County Emergency Medical Services (EMS) to assist with evacuating CAH patients from the facility but was unable to produce a written agreement.

Based on document review and interview, the facility's Emergency Preparedness Plan (EPP) failed to address a means to shelter in place in the event of an emergency. This failure had the potential to affect any/all patients, staff, visitors, and volunteers in the CAH in an emergency. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence that the facility's staff had developed policies and procedures that addressed a means to shelter in place for patients, staff and volunteers who remained at the facility during an emergency.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) was unable to locate policies and procedures that addressed sheltering in place during an emergency.

Based on document review and interview, the facility's Emergency Preparedness Plan (EPP) failed to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency. This failure had the potential to affect all patients receiving care in the facility.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder and policies and procedures showed no documented evidence that the facility's staff had established policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that the facility had no policies or procedures to address securing and maintaining availability of patient records, patient information, or protecting confidentiality of patient information in the event of an emergency. Staff G explained that the facility recently obtained electronic access with its "sister facilities" and now would be able to communicate patient medical information electronically with those facilities when a CAH patient was transferred.

Based on document review and interview, the facility's Emergency Preparedness Plan failed to address the use of volunteers in an emergency and other emergency staffing strategies. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder or Policy Procedure Manuals showed no documented evidence that the facility's staff had developed policies and procedures that addressed the use of volunteers (healthcare professionals and non-medical) or other emergency staffing solutions to protect patients, staff, visitors and volunteers in the event of an emergency.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) was unable to locate policies and procedures that addressed the use of volunteers during an emergency.

Based on document review and interview, the facility's Emergency Preparedness Plan failed to address arrangements with alternative facilities to receive patients in the event the CAH must limit or discontinue services in an emergency. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence that the facility's staff had developed arrangements with alternative facilities to receive patients during an emergency.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) was unable to locate written agreements with other facilities to receive patients during an emergency situation. Staff G explained that the facility had relationships with area hospitals to accept patient transfers, but Staff G did not have documented evidence of these agreements.

Based on document review and interview, the facility's Emergency Preparedness Plan (EPP) failed to address the role of the facility under a waiver declared by the Secretary, in the provision of care and treatment at an alternate care site under the 1135 waiver. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence that the facility's staff had developed policies and procedures that addressed providing care and treatment at alternate sites identified by emergency management officials.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) was unable to locate policies and procedures that addressed providing care and treatment at alternate sites identified by emergency management officials

Based on document review and interview, the facility's staff failed to develop a written emergency communications plan that addressed coordination of care within the facility, across healthcare providers, and with state and local public health departments in the event of an emergency. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence that the facility's staff had developed a written emergency communications plan.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) was unable to locate the facility's written emergency communications plan.

Based on document review and interview, the facility's staff failed to ensure that all contact information in their emergency preparedness communication plan had been reviewed and updated at least annually. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an emergency preparedness communication plan that included names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities and volunteers. There were no Emergency Preparedness or communication plans available for review and/or available for annual updates including all contact information.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) stated that there was not an emergency preparedness communication plan for the facility.

Based on document review and interview, the facility's staff failed to develop an emergency communication plan that complies with Federal, State and local laws and had been reviewed and updated at least annually. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an emergency preparedness communication plan that included the contact information for Federal, State, tribal, regional and local emergency preparedness staff to be reviewed and updated on an annual basis.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) stated that there was not an emergency preparedness communication plan for the facility.

Based on document review and interview, the facility's staff failed to develop and maintain an emergency communication plan that included a primary and alternate means for communication with staff and emergency management agencies. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an emergency preparedness communication plan that included a primary and alternate means of communication with facility staff, Federal, State, tribal, regional and local emergency management agencies. The communication plan was to be reviewed and updated on an annual basis.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that there was not an emergency preparedness communication plan for the facility.

Based on document review and interview, the facility's staff failed to develop an emergency communication plan that complies with Federal, State and local laws and had been reviewed and updated at least annually. The communication plan must include a method for sharing information and medical documentation for the facility's patients with additional health providers. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an emergency preparedness communication plan that included a process for sharing health information and medical documentation for their patients to provide continuity of care.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM), explained that the facility recently gained the ability to share health information electronically with their "sister hospitals" to improve continuity of care for their patients, but there was not a documented emergency preparedness communication plan for the facility.

Based on document review and interview, the facility's staff failed to develop an emergency communication plan that complies with Federal, State and local laws and had been reviewed and updated at least annually. There was not development of a plan that reviewed the means of providing information about the facility's occupancy, needs and its ability to provide assistance to the Incident Command Center. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an emergency preparedness communication plan that included the means of providing information to the Incident Command Center, or designee.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that there was not an emergency preparedness communication plan for the facility.

Based on document review and interview, the facility's staff failed to develop a written training and testing program based on their Emergency Preparedness Plan and ensure that the training and testing program was reviewed and updated at least annually. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an Emergency Preparedness Plan (EPP) or a written training and testing program based on the facility emergency plan.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) explained that emergency preparedness training for the staff had not been developed. Staff G confirmed there was no evidence of an existing training or testing program and therefore, nothing established to review or update annually.

Based on document review and interview, the facility's staff had no evidence of developing a program for emergency preparedness training or receiving annual emergency preparedness training. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no evidence of an Emergency Preparedness Plan, that the staff had developed a written training and testing program based on their emergency plan or that staff received emergency preparedness training at least annually.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) confirmed that there was no evidence of an existing training or testing program and therefore, nothing established to review or update annually.

Based on document review and interview, the facility's staff failed to conduct exercises to test the emergency plan at least annually. This failure had the potential to affect all patients receiving care in the facility. Additionally, this failure potentially hindered the facility's ability to prepare for emergency situations and keep patients safe during an emergency event.

Findings Include:

A review on 02/07/19 of the facility's Emergency Preparedness Binder showed no documented evidence of a full scale and table top exercises conducted to test their emergency plan at least on an annual basis. As a result of exercises to test their emergency plan not being conducted, efforts to identify a full-scale community-based exercise were also not documented.

In an interview on 02/07/19, the CEO, Staff A, stated that she was aware there was no Emergency Preparedness Plan for the hospital. She had nothing to add and deferred any/all questions about EPP to Staff G, Risk Manager.

In an interview on 02/07/19 at 10:30 AM, Staff G, Risk Manager (RM) confirmed that there was no written evidence of yearly emergency exercises for the facility. Staff G explained that an exercise was performed at the facility within the past year but was unable to locate documentation or analysis of the exercise.